Date of Request:
Agent of Record Transmittal Form
Covered California – Individual Exchange
Please complete the information below and send this form to
CCHP
[Insert Contact Entity]
via email at
[email protected] .
[Insert Email Address]
Consumer Information:
Consumer Name:
Covered California System Case No.:
Former Agent Information:
Former Agent Name:
Former Agent License No:
New Agent Information:
New Agent Name:
New Agent License No:
New Agent Phone No.:
New Agent E-mail Address:
Effective Date of Change: